Health insurance claims are denied for a number of reasons including a failure to obtain pre-authorization for a test or procedure. Unfortunately, a denial does not help you pay for your test or procedure. You have a right to appeal the decision of the insurance company and possibly reverse the company's decision. If you are planning to appeal, here are some steps to take.
Get Specifics on the Denial
Before you file an appeal, you need to know exactly why the insurance company chose to deny your claim. The insurance company is required to send you a letter detailing the reason for the denial. Some companies deliberately opt to use codes to explain the reasoning, which can be confusing to customers.
If you are not clear on why your claim was denied, contact the insurance company. Ask for an explanation of the codes. When calling, make note of each person you speak with and the department in which they work. You should also ask for a more simplified denial letter.
In addition to the explanation, ask your insurance provider to mail you a copy of the full policy. In some instances, the policy is available to view online. If so, print it out.
Ask Your Doctor to Re-Submit the Claim
In some instances, claims are denied due to the language that was used in the claim. After reviewing the denial letter and the policy, you should have a better understanding of what led to the denial. If the denial was prompted by a lack of information from the doctor or confusion on the medical necessity for a procedure, ask your doctor to re-submit the claim.
Ask your doctor to be thorough in his or her claim. The smallest details can make a difference. Ask for a copy of the claim for your own personal records.
Request an External Review
If the insurance company denies your claim again, you can ask for an external review. The Affordable Care Act requires that each state have an external review process to assess denied insurance claims. The request has to be filed within 60 days from the denial. If the external reviewer decides in your favor, the insurance company has no choice but to approve the procedure.
Navigating insurance appeals can be challenging. To improve the odds that your denial will be overturned, consult with a local insurance disputes lawyer like those found at Bidegaray Law Firm LLP. He or she would be up-to-date on state and federal laws that can be used in your favor and help build the appeal.Share